Physician Compare National (NPI:1497816698)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1497816698
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	0042483794
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20111025000877
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	LOGAN
	Individual professional last name
Provider First Name	RUSSELL
	Individual professional first name
Provider Middle Name	WARREN
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	CLEVELAND CHIROPRACTIC COLLEGE - KANSAS CITY
	Individual professional's medical school
Graduation Year	1977
	Individual professional's medical school graduation year
Primary Specialty	CHIROPRACTIC
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	911 GULF ST
	Group Practice or individual's line 1 address
City	LAMAR
	Group Practice or individual's city
State	MO
	Group Practice or individual's state
Zip Code	647591406
	Group Practice or individual's zip code (9 digits when available)
Phone Number	4176823466
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	M